Coverage of the Costs for the Treatment of Cluster Headaches with the Medication Sumatriptan-Mepha

Facts

A., born in 1977, is compulsorily insured for medical care with the Atupri health insurance. By decision dated December 30, 2013, Atupri agreed to cover the costs of the medication Sumatriptan-Mepha for the treatment of the insured's cluster headaches within the maximum dosage according to the official authorization (12 mg daily). However, the costs of the drug Relpax and any other triptans would not be reimbursed simultaneously with the use of Sumatriptan-Mepha.

In response to the insured's objection, in which he referred to reports from the treating physician and other specialists, the health insurer obtained, among other things, an expert opinion from the Medical Evaluation Center (MEDAS) Eastern Switzerland and a report from a specialist in neurology. Based on this, Atupri rejected the objection and refused to cover the costs of the medications Sumatriptan-Mepha and Relpax outside the Swissmedic authorization, as well as to extend the cost coverage to any other triptans.

The appeal filed against this was partially upheld by the High Court of the Canton of Schaffhausen. It obligated Atupri to retroactively and continuously cover the costs of unlimited use of the medication Sumatriptan-Mepha (injection solution) according to the prescription of the treating physician, as long as no adequate alternative treatment is available.

Atupri appeals the decision in public law matters and requests the annulment of the lower court's decision.

Considerations

The social health insurance provides benefits, among other things, in the event of illness. Within the framework of the compulsory health insurance, the insurers may not cover any other costs than those for the benefits according to Articles 25-33 of the Federal Health Insurance Act (KVG). This also includes the costs for the medicinal products prescribed by physicians on the Specialty List (SL).

In addition to the effectiveness, appropriateness, and cost-effectiveness of the treatment, the prerequisite for cost coverage in individual cases is that the use of the medication is within the approved medical indications and dosages by the Therapeutic Products Agency (Swissmedic) and in accordance with the limitations under Article 73 of the Health Insurance Ordinance (KVV).

Exceptionally, the costs of medicinal products not listed in the SL and of…